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  • Education Residents Resident Edition

    Ophthalmic Drops 101

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    I started ophthalmology residency confident that I was at the top of my game. So when my upper level told me to go “start the drops” on a new patient, I was humbled by my ignorance of the rainbow of little bottles. Why hadn’t this been covered in pharmacology?

    This is an introduction to the most common drops you’ll encounter in the first few months of residency. It also includes indications as well as cautions. This is not a comprehensive list, nor should these descriptions be a substitute for medical advice or training. Eyedrops have multiple indications and side effects beyond what is listed here.

    In the charts below, the brand name is listed in parentheses if it has not yet become generic.

    Anesthetic Drops

    Drug Lid Color
    		 Duration Indications Cautions
    Proparicaine
    (Alcaine)

    Tetracaine
    (Pontocaine)    		 White 10–30 min Topical anesthesia

    Breaks down corneal epithelium ulcers

    Speeds absorption of subsequent drops    		 Long-term use causes corneal ulcers

    Check corneal sensation before use in setting of ulcers
    Benoxinate + Fluorescein
    (Fluress)    		 N/A, dropper 10–20 min Applanation tonometry

    Stains defects on corneal/conjunctival surface

    Topical anesthesia    		 Not for Seidel tests (use fluorescein paper strips)

    Patients may see yellow when they blow their nose

    Dilation Drops

    Drug Lid Color
    		 Duration Indications Cautions
    Phenylephrine 2.5%, 10%
    (Neosynephrine)    		 Red 3 hours Use with tropicamide for adult dilation Avoid 10% in hypertensive crisis, pediatrics and the elderly
    Tropicamide 1%
    (Mydriacil)    		 Red 4–6 hours Use with phenylephrine for adult dilation  
    Cyclopentolate 1%, 2% (Cyclogyl) Red 24 hours Cycloplegic refractions  
    Homatropine 2% Red 1–2 days No longer manufactured  
    Atropine 1% Red 7–10 days Breaks posterior synechiae

    Decreases ache from ocular inflammation

    Fogging for amblyopia treatment    		 Avoid in angle-closure glaucoma

    Glaucoma Drops

    Drug Lid Color
    		 Dosing Class Cautions
    Timolol 0.5%
    (Timoptic)    		 Yellow BID Beta blocker Avoid in patients with asthma, COPD, CHF and bradycardia
    Brimonidine 0.1%, 0.15%, 0.2%
    (Alphagan)    		 Purple BID-TID Alpha agonist Avoid in patients under 3 years of age

    Avoid in nursing women (only class B med)
    Dorzolamide
    (Trusopt)    		 Orange TID Carbonic anhydrase inhibitor Avoid in sulfa allergy

    Avoid in sickle cell patients with hyphema (can induce sickling in anterior chamber)

    Patients may complain of bitter or metallic taste
    Bimatoprost 0.01%, 0.03%
    (Lumigan)

    Travoprost 0.004%
    (Travatan Z)

    Latanoprost 0.005%
    (Xalatan)    		 Teal green Qhs Prostaglandin agonist May reactivate herpes simplex virus keratitis

    Darkens hazel irides

    Conjunctival hyperemia is common

    Avoid in uveitic glaucoma and pregnancy
    Dorzolamide/Timolol 0.5%
    (Cosopt)    		 White with dark-blue strip BID Carbonic anhydrase inhibitor + beta blocker  
    Brimonidine 0.2%/Timolol 0.5%
    (Combigan)    		 Dark blue BID Alpha agonist + beta blocker  
    Acetazolamide
    250-mg tabs,
    500-mg sequel (caps),
    slow release
    (Diamox)    		 N/A BID Carbonic anhydrase inhibitor Avoid in sulfa allergy

    Avoid in sickle cell patients with hyphema (can induce sickling in anterior chamber)

    Avoid in patients with a history of kidney stones

    Beware with potassium-losing diuretics or digitalis

    Common side effects include peripheral limb tingling/weakness, bad taste with carbonated beverages and diarrhea
    Methazolamide
    25-mg tabs
    (Neptazane)    		 N/A BID- TID Carbonic anhydrase inhibitor Same as above, but less severe

    Steroid Drops

    (In order from strongest to weakest)

    Drug Lid Color
    		 Indications Cautions
    Difluprednate 0.05%
    (Durezol)    		 Pink Postoperative inflammation

    Iritis    		 Causes highest incidence of elevated IOP and cataracts compared with steroid drops below
    Prednisolone acetate 1%
    (PredForte)    		 Pink/white Postoperative inflammation

    Iritis    		 Can cause elevated IOP and cataracts
    Fluorometholone 0.1%
    (FML)

    Loteprednol 0.5%
    (Lotemax gel)    		 Pink/white Ocular surface inflammation/dry eye

    Postoperative inflammation    		 Can cause elevated IOP and cataracts, but to a much lesser extent than the two above
    Loteprednol 0.2%
    (Alrex)    		 Pink/white Seasonal allergies  

    Antibiotic Drops

    Drug Lid Color
    		 Indications Cautions
    Moxifloxacin
    (Vigamox)

    Gatifloxacin
    (Zymaxid)    		 Tan Fourth-generation fluoroquinolone

    Postoperative

    Corneal ulcers    		  
    Ofloxacin
    (Ocuflox)    		 Tan Third-generation fluoroquinolone

    Postoperative    		  
    Erythromycin
    (Emycin)    		 N/A,
    ointment/tube    		 Macrolide

    Bacterial conjunctivitis

    Sterile cornea defects to prevent infection

    Prevents ophthalmia neonatorum    		  
    Bacitracin ointment
    (Bacitracin)    		 N/A,
    ointment/tube    		 Cationic polypeptide

    Methicillin-resistant Staphylococcus aureus    		  
    Tobramycin/
    Dexamethasone ointment
    (Tobradex)    		 N/A,
    ointment/tube    		 Aminoglycoside

    Gram negatives (Pseudomonas)    		  
    Neomycin/
    Polymyxin/
    Dexamethasone ointment (Maxitrol)    		 N/A,
    ointment/tube    		 Aminoglycoside + cationic polypeptide + strongest topical steroid

    Postoperative

    Common gram positives    		 Neomycin is the most common cause of contact dermatitis

    * * *

    Natasha L. Herz, MDAbout the author: Natasha L. Herz, MD, is a cataract, corneal and refractive surgeon who works as a solo practitioner at Kensington Eye Center in Washington, D.C. Dr. Herz has been chair of YO Info’s editorial board since 2012. She is also a member of the Academy’s Communications Committee.